PROJECT SUMMARY Significant and increasing health disparities exist in Central Appalachia (encompassing parts of WV, KY, TN and VA) compared to other U.S. regions, yet research addressing environmental factors contributing to these health disparities is lacking. Central Appalachia offers a unique opportunity to examine environmental exposures associated with resource extraction. Coal production from large surface mines was the dominant resource extraction method in the 1990s-2000s and is now decreasing as other resource extraction methods increase. We hypothesize that health risks associated with air and water pollution are increased in Central Appalachian residents living within close proximity to active surface mines. The research proposed here extends our preliminary work in Appalachian communities assessing perceptions of health risks and water quality and fills a critical data gap in the literature, moving beyond county-level ecological studies to link exposure with health outcomes. We propose to: 1) spatiotemporally characterize airshed and watershed boundaries associated with surface mining between 1990 and 2015, and 2) determine associations between adverse birth outcomes and living within active surface mine boundaries during pregnancy. Using a natural experiment design, we will build a retrospective longitudinal cohort of pregnancies resulting in live births between 1990 and 2015 within and outside of air and watershed boundaries of surface mines based on geocoded birth records. We propose innovative methods for defining fine spatial (30m) and temporal (monthly) resolution air and watershed exposure boundaries by combining satellite derived datasets to estimate land use change, air transport modeling, and watershed delineation. Within surface mining airsheds and watersheds, individual pregnancies will be categorized as occurring pre-, during, or post- active surface mining. Using an extension of a difference in differences approach, the proposed research will improve inference and precision in effect estimates by reducing bias associated with unmeasured confounding and secular trends in adverse birth outcomes. The proposed research will aid in defining the causal underpinnings of health disparities in Central Appalachian communities, ultimately leading to research, policy and practice improvements that may be generalizable to other areas beyond Central Appalachia where surface mining is prevalent.